We are all guilty of carrying with us unconscious bias which affects the decisions we make, but care must be taken to ensure that this does not affect the way patients or staff are treated
Mirror, mirror on the wall. We all do it. We know we do it. And – more than that – science has now proven that we do it. It’s called unconscious bias. You’ve probably read about it.
What you may not have read is one of the leading titles in this area Thinking, Fast and Slow by Daniel Kahneman. Kahneman’s book is responsible for a lot of the talk about unconscious bias. The book is no fairytale - it’s hard to read, extremely intense and even includes a couple of research papers as appendices. But the overall message he conveys is the simple basis of unconscious bias – which is that our brains operate through two systems (system one and system two; conscious and unconscious) – and that the unconscious is by far the quicker, more powerful and more ingrained of these two.
‘So what’s that got to do with diversity and health inequalities?’ I hear your unconscious brain asking. Well – everything! But let’s keep it simple and look at this at three levels: individual, organisational and system.
At an individual level, unconscious bias would suggest that how we present ourselves to others, how we see the world, so how we approach the whole area of diversity will be strongly influenced by our natural biases. Therefore, it will be extremely difficult for a straight woman to understand the world through the eyes of a lesbian woman and extremely difficult for an Indian man to see the world through the eyes of a Chinese man – because of their different life experiences.
Applying unconscious bias to what I have just written (which assumes the concept of sight), it would also be extremely difficult for a fully sighted person to imagine how the world appears to a blind person. I could of course go on and on with these sorts of examples. But the point is not to try to identify every possible prejudice that you or I might have as individuals. The point is to recognise that these prejudices exist and then to try and find ways of getting ourselves and others to understand how this might affect how we present, how we think and (most importantly) how we act. This can be done through self-learning, group training or simple awareness raising.
If we move to the next stage – the organisational level, then the biases and prejudices that we hold both personally and collectively (as a group of people who form that organisation – whether it be a small GP practice or a global financial bank) will very much influence what the priorities of that organisation are and how the organisation seeks to achieve those priorities.
Again, the secret here is not to try and analyse and scrutinise every organisational policy and practice that you have and to dismantle and reassemble it. The secret is to recognise that this is happening – and to proactively question and challenge it. In the world of diversity and health inequalities, this is where our old friend data is so important, and the old adage ‘what gets measured, gets counted’ comes into play.
Therefore – going back to the examples I gave above around individual biases – unless you
monitor and measure sexual orientation, ethnicity and disability, you will not know whether your policies or practices are biased. You will not know whether you have a tendency to recruit only white, non-disabled, straight staff unless you have a monitoring system in place which firstly asks these questions and secondly analyses the data in such a way that it allows you to investigate this.
But organisational unconscious bias is about more than data, and includes looking at who and what determines and drives the organisational policies and strategies that form an important part of your business. So, does your organisation have (or has it even considered) a flexible working policy? Does your organisation have a special leave policy? If so, does this policy allow for same sex partners to have time off work if their partner is unwell? Does your flexible working policy allow for home working? If not, why not? All of these things are questions that the organisation needs to ask themselves if they want to be a fully inclusive employer – but they are not questions that might naturally occur to some people.
Moving on to systems issues – how does unconscious bias affect the wider working of the business or organisation? GP practices are one part of a wider health and social care system within all communities. Those systems have generally evolved over a period of time, adjusting to accommodate social and structural changes across the area. But how much have they adjusted and accommodated to meet the needs of all of the community? How well does the system serve the whole community? How accessible and relevant are the services that are provided to all of your community? Our old friend data again plays an important part here.
You will probably be aware of the Marmot review that showed there were some stark and startling discrepancies and anomalies in the health outcomes of different groups within our society. What I found most interesting from all of the information that the Marmot review produced was how variable these differences were region by region. One of the most popularly reported statistics that Marmot cites relates to the journey along the Jubilee Line in London where life expectancy goes down by one year as you travel east along the line. But this statistic is even more stark in some rural areas where the geography is bigger and the lifestyles much more diverse. And within these high level statistics of course lie even starker variations for vulnerable groups such as sex workers and the homeless.
So how does your organisation do on this level? Do you know what the health inequalities in your area are? Do you know who the most vulnerable groups in your area are? More importantly, do you know what those groups think about this? Are you engaged with them? Have you done more than send out a survey? Have you actually gone out and spoken to these groups (remembering that they will often not naturally come to you)? And when you do go out to these groups – what prejudices and unconscious biases do you take with you? And what prejudices and unconscious biases do they hold about you in return? Again, this is not about torturing yourself with endless questions, it is just about being aware of the issues and knowing that the questions exist. It is about being able to hold a mirror up to yourself, your organisation and your community and to ask whether what you see is really what you see.
Mirror, mirror on the wall…
Paul Deemer is head of equality, diversity and human rights at NHS Employers